Ob-Gyn Coding Alert

Bolster your bottom line by finding out what codes you can bill in addition.

If you want your annual visit claims to be picture perfect in 2011, then follow these five tips to avoid future denials. You'll be the envy of your colleagues, as your ob-gyn claim will be on the fast track to success.

Background: The Affordable Care Act (ACA) extended preventive coverage to more than 88 million patients covered by health insurance, and Medicare has codified that benefit in the form of an annual wellness visit. Medicare valued the new annual wellness codes based on a level 4 problem new and established E/M service. The two new codes are:

• G0438 -- Annual wellness visit, including personalized prevention plan services, first visit
• G0439 -- Annual wellness visit, including personalized prevention plan services, subsequent visit

Tip 1: Apply G0438 to Second Year of Coverage

Be wary of applying these codes to new Medicare patients coming in to your ob-gyn practice in 2011.

The reason is that Medicare will only reimburse the initial visit (G0438) during the second year the patient is eligible for Medicare Part B. In other words, during the first year of the patient's coverage, Medicare will only cover the Initial Preventive Physical Exam (IPPE) or the Welcome to Medicare exam.

Tip 2: CMS Limits G0438 to One Physician

If your ob-gyn sees the patient for the initial visit (G0438) and the patient sees a different obgyn for the next annual wellness visit, that second ob-gyn will only receive reimbursement for the subsequent visit (G0439), despite having never seen the patient before. CMS has indicated that when a patient returns to the same or new physician in a third year, they may only pay for the subsequent visit, says Melanie Witt, RN, COBGC, MA, an independent coding consultant in Guadalupita, N.M. "It is therefore important that you convey this information to any new physician the patient sees."

Tip 3: Add Preventive Service Codes, If Performed

You can bill these annual codes in addition to any other preventive service, such as G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination) and/or  Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) in the covered year.

Keep in mind: You won't need to append any modifier (such as 25, Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) for this combination because the G codes are not problem E/M services to which that modifier applies. If you do report the annual codes with a problem E/M service with modifier 25, CMS indicates that this situation should be "rare, due to the nature of the wellness visit requirements which are very time intensive," Witt says. "They also expect that given these requirements, you will not bill the patient for a non-covered preventive service in addition."

Tip 4: Document At Least Six Elements

In order to bill the new annual visit codes, the physician or physician team must document the following six elements (at a minimum):

• Establish or update the individual's medical and family history. List the individual's current medical providers and suppliers and all prescribed medications.
• Record measurements of height, weight, body mass index, blood pressure and other routine measurements.
• Detect any cognitive impairment.
• Establish or update a screening schedule for the next 5 to 10 years including screenings appropriate for the general population, and any additional screenings that may be appropriate because of the individual patient's risk factors.
• Furnish personalized health advice and appropriate referrals to health education or preventive services.

Heads up: Notice your physician has no requirements for a physical examination other than vital signs and other routine measurements. CMS clarified that these above six elements are the minimum to get by. If your provider feels that more should be documented, then he should do so, but CMS will not give any extra credit. Also, you should not bill the annual wellness visit as an "incident-to" service. When a team of medical professionals are working together to provide the service, the billing physician must provide direct supervision.

Tip 5: CMS Waives the Deductible and Copay

Under provisions listed in the ACA, all plans (private and government funded) covered by the rules contained in the Act must offer coverage of a comprehensive range of preventive services that are recommended by experts and the U.S. Preventive Services Task Force (USPSTF) with a grade of A (strongly recommends) or grade B (recommends). This means these codes fall under coverage that does not impose any cost- sharing requirements.

What this means to you: To comply with this requirement, Medicare waived both the copay and the deductible for a patient's annual wellness visits, the IPPE exam, and other preventive services that meet the "A" and "B" USPTF recommendations.

You may already know that the screening laboratory services have always been exempt from the copay and deductible, but do you know the other exempt services? 

The covered preventive services other than lab tests (CPT 8xxxx or HCPCS G codes) for which CMS waives both the deductible and copay in 2011 include:

• IPPE exam: G0402
• Smoking and Tobacco Cessation Counseling: G0436, G0437
• Screening Pelvic/Breast exam: G0101
• Screening Pap Smear Collection: Q0091
• Medical Nutrition Therapy Services: 97802-97804, G0270-G0271
• Screening Mammography: 77052, 77057, G0202››
• Bone Mass Measurement: G0130, 77078-77083, 76977
• Colon Cancer Screening: G0104, G0105, G0121

Cutting edge: According a member of the CPT Editorial Panel at the AMA annual CPT Symposium, CPT will be adding a new modifier 33 to indicate that the service you're billing does not permit cost sharing under the ACA rules. In the future, you would add this modifier when you submit a claim for a  mandated preventive service to a private payer, this member said. "That modifier does not appear in the 2011 CPT book, but might be added at a later date, so stay tuned," Witt says.